Effective Reporting and Record Keeping in Health and Social Care Services

This document discusses the importance of reporting and record keeping in health and social care services. It explores the current digital and manual processes used by Caring Homes Ltd and the reasons for sharing information within the organization and with external bodies. It also identifies the statutory requirements for reporting and record keeping and the consequences of failing to comply. The effectiveness of using digital technology and involving service users in record-keeping processes is evaluated. Finally, a digital care plan is produced and its effectiveness in meeting service user needs is assessed.

Effective Reporting and Record
Keeping in Health and Social
Care Services
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Table of Contents
INTRODUCTION...........................................................................................................................3
TASK 1............................................................................................................................................3
P1 Provide an introduction of your organization which clearly evaluate the current digital and
manual process.......................................................................................................................3
P2 Explain the reasons for sharing information within own setting and with external bodies.
................................................................................................................................................4
TASK 2............................................................................................................................................5
P3 Identify statutory requirements for reporting & record keeping for your health care setting
meeting the requirements of a inspecting body......................................................................5
P4 Based on above identified statutory requirements, demonstrate the internal and external
requirements for recording information in own care setting..................................................6
External requirements for recording information in Caring Homes Ltd are discussed below.
................................................................................................................................................6
P5 Explore the consequences of failing to comply with requirements of statutory and
inspecting bodies....................................................................................................................6
TASK 3............................................................................................................................................7
P6 Review and evaluate the effectiveness of the use of digital technology to meet the service
user needs, ensuring appropriate care is given while maintaining confidentiality.................7
P7 Explain the benefits of involving service users in record-keeping processes in your care
setting.....................................................................................................................................7
TASK 4............................................................................................................................................8
P8 Produce digital care plan and evaluate the effectiveness in terms of meeting the service
user needs...............................................................................................................................8
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P9 Conclude with recommendations for improvements within your own practice...............9
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................10
INTRODUCTION
Reporting and record keeping are the most important aspects of a health and social care
practitioners. An accurate report or record keeping is necessary in healthcare sectors as it forms
an essential part of delivery of care or management of the service users (Alfoghi and Ramadan,
2017). However, it also helps in circulation of information between different teams which are
involved in treatment of patient. In this report, Caring Homes Ltd has been chosen. It is a
healthcare organisation in UK which provides support and care services to the citizens of UK
with a chain of care facilities for the individuals. The following report is going to cover Internal
and external recording requirements in a care setting. Furthermore, it will focus on Legal and
regulatory aspects of reporting and record keeping .At last Use of technology in reporting and
recording will be cover.
TASK 1
P1 Provide an introduction of your organization which clearly evaluate the current digital and
manual process
Caring Homes Ltd is a health and social care sector which provide care facilities to the
individuals of United Kingdom. The respective organisation goes through digital and manual
processing for keeping records of their service users. The digital process use by the organisation
in respect to patient records are discussed here.
Storing: It is a computer based record keeping. Records of the patients are stored in a
system and which is design to provide store all necessary data of patient treatment. It provides
accurate alerts, data, clinical support systems and provide links to medical knowledge.
Maintaining: Electronic health record is a method for maintaining records of the
patients. It provide space for patients demographics, medical histories, diagnosis, immunization
dates and many more.
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Sharing patients records: IT digital systems are available nowadays for sharing
information of the patient treatment across external and internal department with could be
handled remotely.
Manual process for record keeping in respective organisation is discussed as follows.
Storing: It is basically a book keeping or documentation where the records are stored and
maintained through hand process. Information of the patients are handled by care practitioners
itself by maintaining a file or document.
Maintaining: Records of the patients are maintain in a document and calculations for the
bill and audits are done in a file and are mostly hand written.
Sharing patients records: Information regarding patient treatment are shared by
transferring of file from one department to another. Documents are shared between care
practitioners for sharing information.
Difficulties were faced during maintaining and storing of patients records manually. As it
is a hand written process there are chances of risks and errors that could be occur and it is then
risky for the patient if they get any wrong treatment (Chauhan and et.al., 2016). Thus, along with
being beneficial maintaining and storing records digitally are easy and it gives accurate data
along with proper access to all necessary information needed for the treatment process of service
users.
P2 Explain the reasons for sharing information within own setting and with external bodies.
Information sharing is a process of passing information from one department to another.
All health and social care organisation are required to share information of the patients they are
looking for within the department and to external bodies for improving the quality of care
delivering to the patients. In Caring Homes Ltd it is essential to implement information sharing
process in order to deliver high quality of services to their service users. It is important to share
information within the care settings as it helps to develop a stronger relationship between the
care practitioners and help them to solve problems more effectively (Cornock, 2019). It enables
faster decision making process as it include the views and opinions of different professionals
within the organisation. Sharing health records of patients will help to improve specific
treatment, speed up diagnosis process, and enables care practitioners to plan new treatment or
make necessary changes in the treatment process.
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It is necessary for the respective organisation to share patient records with other external
parties as it will help them to deliver better care to their service users. It is important to know the
opinions and suggestions of external care practitioners and health professionals as it help to
know more about the treatment process of patients and help to make necessary changes within
ongoing treatment. However, considering opinions and advices of external stakeholders is a
better option rather than conducting the overall treatment with a doubt of occurrence of some
risk and errors in the process (Faruq and Tatnall, 2016). It will help respective organisation to
make a strong brand image and will be beneficial to support their service users in more effective
way.
TASK 2
P3 Identify statutory requirements for reporting & record keeping for your health care setting
meeting the requirements of a inspecting body.
Record keeping is important for detailing all necessary aspects of patient's monitoring
process. However, recording and report keeping in Caring Homes Ltd are need to meet all legal
requirements. It is beneficial for service users. Such legal guidelines and policy is discussed
below.
Health and Social Care Act 2008: The legal requirements for keeping records in
healthcare services are mentioned in regulation 20 of this particular act. The law says that care
practitioners must maintain accurate records and a relevant documentation of the patients taking
the services. A record must be kept for an appropriate period of time and after that it must be
destroyed securely.
Data protection act: The main objective of this act to control the utilization of personal
information of individuals by the organisation. Health and social care organisations are need to
follow all necessary guidelines of this particular act. Information should be used fairly,
transparently and lawfully (Gorst and et.al., 2016). Confidentiality and privacy of data must be
maintained during storing and maintaining of data. Service users must be informed about how
their data is being used by the organisations.
Human rights act: The human right act suggest that there should be fairness, respect,
dignity and equality in the treatments of individual in health and social care organisation. Thus,
for maintaining an storing records there must be no discrimination and inequality between
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patients or service users. Confidentiality and privacy of the data must be consider by the
healthcare practitioners during the overall treatment process. Practitioners must have increased
knowledge of understanding and capabilities for meeting the duties of protection, respect and
must promote human rights within the organisation and should address inequality. Improve care
experiences of patients is also mentioned in human rights act (Hastings, 2018).
P4 Based on above identified statutory requirements, demonstrate the internal and external
requirements for recording information in own care setting.
Recording information involves all paper work and digital systems which are need to be
maintained by the care practitioners for fulfilling the requirements in the areas like health and
safety, legal protection, medical and care records. Internal requirements for record keeping in
Caring Homes Ltd are discussed here.
 According to health and social care act, care practitioner must securely maintain an
accurate, finished and existing records for proper care and treatment provided to the
service users and for taking decisions related to treatment being provided.
 According to the data protection act, confidentiality and privacy of information is the
integral part for the services users of the organisation. Hence, it is the responsibility of
health professionals to maintain privacy and confidentiality of all the information of
patients.
External requirements for recording information in Caring Homes Ltd are discussed below.
 External requirements are there should be proof of identity of all health care practitioners
within the organisation.
 There must be certification of their degree that they have knowledge of care practices and
they are able to provide treatments to the individuals.
P5 Explore the consequences of failing to comply with requirements of statutory and inspecting
bodies.
Failure to comply with requirements of statutory and inspecting bodies could led to
number of consequences. For not following data protection act, a large amount of fine could be
ask with respective organisation. At first a written warning is send to the organisation which
must be taken seriously by them. Many of the inspecting bodies such as CQC also include fines,
disqualification and imprisonment. Fixed penalty notice is given to organisation by CQC
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inspectors. There are chances that such statutory and inspecting body could cease the
organisation for a long duration or permanently. If a care practitioner is failed to keep
confidentiality of information, service users can file a case against him/her as it is consider as an
offence in United Kingdom. However, in context to Caring Homes Ltd benching of such
legislation could lead to serious consequences for both service users and for organisation.
Criminal charges are the most potential consequence for non-compliance of such bodies.
TASK 3
P6 Review and evaluate the effectiveness of the use of digital technology to meet the service user
needs, ensuring appropriate care is given while maintaining confidentiality.
The main purpose of the health technology is to provide a high quality of care to the
service users and to achieve equity in health. In Caring Homes Ltd digital technology will help
the care practitioners to perform effectively with the use of machines and equipments. It is use to
identify, analyse and to share health records of patients (HENA, 2018). Number of technology
involves health record systems, health tools and applications which help the individuals to
maintain their health conditions. However, the main objective of technology is to record patient
data for improving delivery of healthcare that allow access for this information to healthcare
practitioners and service users. Health technology ensure the confidentiality of patient data as it
has limited access and their data is more secured. It improves patient safety, reduce risks in
treatment and change the relationship between service users and care practitioners. It provide
accurate records of patients and allows care practitioners to better understanding of health
conditions of patients by their medical history. Appropriate care has been given to the patients in
respective organisation through utilization of technology in their organisation.
P7 Explain the benefits of involving service users in record-keeping processes in your care
setting.
Service user involvement can be define as a process through which individuals who are
using services in an organisation or who have used services of certain organisation get involved
in planning, development and delivery of that specific services. Involvement of service users in
record keeping process will lead to improved quality of care, enhanced quality of life, better
relationships between care practitioners and service users and better outcomes for both service
users and providers. Personal information about health condition of an individual is sensitive and
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need to be maintained with proper confidentiality (Kimei and Kalegele, 2017). Thus, involving
service users in recording keeping process will be beneficial as accurate information about their
medical histories and current health status could be obtained. It will improve satisfaction level of
individuals and thus build a trust between care practitioners and service users. It will improve the
information access for service users and will have a positive impact on decision making process
during the treatment of patients. Thus, overall it will enhance the involvement of a patient in
his/her own treatment and they will get to know about all necessary information. In record
keeping process service users are responsible for ensuring that their information is going only to
their personal care practitioners and there should be no involvement of any third party in the
treatment process.
TASK 4
P8 Produce digital care plan and evaluate the effectiveness in terms of meeting the service user
needs
The digital care plan refers to use of various software and technologies to improve
involvement of services users in planning and decision making. It is observed that specific
guidelines and regulations are required to be followed by given organisation to establish digital
care plan for satisfying individuals. However, it is an effective approach because patient can
share their preferences to doctors through advanced websites by recording them to gain
appropriate services (Mars and Scott, 2016). Thus, desired step of digital care plan which should
be followed by Caring Homes Ltd are mentioned below.
 Initially, it is necessary to ensure authentication regarding information of care plan for
specific health problem.
 Secondly, it is essential to consider the factor of access control and audit trails so that any
kind of misconduct will not happen.
 Thirdly, it consist to make sure physical security of communication, computer and
display system by effective software to maintain legal requirements of Data Protection
Act.
 However, it includes to ensure about control of external communications links and access
by following General Data Protection Regulations (2018) and principles.
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 Meanwhile, it involves to consider the exercise of software discipline across the
organisation by focusing on guidelines of Privacy and Electronic Communications (EC
Directive) Regulations 2003.
 Moreover, it is significant to maintain system backup as well as disaster recovery
processes in terms of recovering the confidential & important clinical data.
 Additionally, it is essential to make sure about system self assessment and maintenance
of technological awareness.
P9 Conclude with recommendations for improvements within your own practice
Considering the above information, it has analysed that various effective principles,
regulations and guidelines should be followed in selected care home in order to improve own
practice while preparing and providing digital care plan (Moriarty and et.al., 2019). It is
necessary for Caring Homes Ltd to follow desired strategies and way of using digital tools for
delivering accurate digital care plan to fulfil actual requirements of patients in appropriate
manner. Some of recommendations are for given care home are examined here.
Legislations: It has been recommended that legal regulations must be followed to deliver
digital care plan for improving health of service users by addressing their actual needs
appropriately. It includes several rules such as Data protection act, Health & social care act,
Privacy and Electronic Communications (EC Directive) Regulations 2003 and many more.
Authentic information: It is suggested to given care home to share authentic information
and make sure that the data should be shared to desired services users only. It is essential for care
professionals to perform their task of preparing digital care plan carefully to satisfy requirements
of patients.
Human rights: It has been recommended that human rights should be considered by
care practitioners while dealing with people and providing digital care plan for their wellness.
CONCLUSION
From the above study, it can be concluded that reporting an record keeping is necessary
in health an social care sectors as it will help to monitor detailed information of the patient. An
accurate report or record keeping is necessary in healthcare sectors as it forms an essential part
of delivery of care or management of the service users. It can be concluded that manual process
for storing an keeping record is difficult in comparison to digital process which gives exact
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results. Requirements of the statutory and inspecting bodies in record keeping and reporting has
been discussed which shows requirements of health and social acre act and data protection act.
REFERENCES
Books and journals
Alfoghi, M. and Ramadan, M.B., 2017. Clinical Record Keeping Survey of Patients Admitted to
Misurata Central Hospital. Annals of International Medical and Dental Research.3(4). pp.1-5.
Chauhan, M., and et.al., 2016. Assessment of newborn care corners in selected public health
facilities in Bihar. Indian journal of public health. 60(4). p.341.
Cornock, M., 2019. Record keeping and documentation: a legal perspective.Orthopaedic &
Trauma Times. (35). pp.34-38.
Faruq, Q.O. and Tatnall, A., 2016. Adoption of ICT in Implementing Primary Health Care:
Achievements of the Twenty-First Century. International Journal of Actor-Network
Theory and Technological Innovation (IJANTTI). 8(1). pp.55-64.
Gorst, S.L., and et.al., 2016. Choosing important health outcomes for comparative effectiveness
research: an updated review and user survey. PloS one. 11(1). p.e0146444.
Hastings, M., 2018. Allied health records in the electronic age. In Managing Money,
Measurement and Marketing in the Allied Health Professions (pp. 96-111).CRC Press.
HENA, N., 2018. A study of HR Data Base Management (HRDM) and Record Keeping for
Analytical Decision Making and Harmonious System within an Organization.
Kimei, E. and Kalegele, K., 2017, May. Digitization of antenatal health card and integration with
OpenMRS platform: System analysis and design. In 2017 IST-Africa Week Conference
(IST-Africa). (pp. 1-7). IEEE.
Mars, M. and Scott, R.E., 2016. Whatsapp in clinical practice: A literature.The Promise of New
Technologies in an Age of New Health Challenges. p.82.
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